Vancomycin powder may reduce gram-positive surgical site infection after fracture fixation
Use of intrawound vancomycin powder during fracture fixation of tibial articular fractures may reduce the risk of gram-positive deep surgical site infections among patients at high risk for infection, according to published results.
Robert V. O’Toole, MD, and colleagues in the Major Extremity Trauma Research Consortium randomly assigned 980 patients with either a tibial plateau or pilon fracture who were at high risk for infection to undergo a standard infection prevention protocol with (n=481) or without (n=499) 1,000 mg of intrawound vancomycin powder during plate and screw fixation. Researchers considered deep surgical site infection (SSI) within 182 days of definitive fracture fixation as the primary outcome, while secondary outcomes included superficial SSI, nonunion and wound dehiscence. Researchers used a post hoc comparison to assess the treatment effect on gram-positive and gram-negative-only infections.
Results showed 29 patients in the treatment group and 46 patients in the control group experienced deep SSI within 182 days. Researchers found a time-to-event estimated probability of deep infection by 182 days of 6.4% and 9.8% in the treatment and control groups, respectively. Post hoc analysis showed vancomycin powder resulted in a reduction of gram-positive infections, according to results.
“The study is important because, even though the use of topical vancomycin powder has grown more popular in orthopedic trauma and other areas of orthopedics, this is the first large, randomized trial to support this practice,” O’Toole told Healio Orthopedics. “The results support the biologic rationale in that the effect was only observed in bacteria that are sensitive to vancomycin and not in other types of bacteria. We believe that topical vancomycin powder is a promising new technology as it is low cost, appears to have little risk of systemic complication and helps address the devastating issue of surgical site infection that has important consequences both to individual patients and society in a broader sense.”
Perspective
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This landmark paper demonstrated that the use of intrawound vancomycin powder during fixation of high-risk tibial fractures was associated with a significant reduction in gram-positive deep surgical site infections. While all orthopedic surgeons should practice good antibiotic stewardship, this randomized controlled trial provides strong evidence that the use of intrawound vancomycin powder can provide a safe and effective adjunct to systemic antibiotics in the overall reduction of deep surgical site infections in high-risk patients undergoing fracture surgery.
One cannot help but wonder if intrawound vancomycin powder can be extrapolated to other subspecialty surgeries in orthopedics. While spine surgery was the first to show a decrease in surgical site infections with the use of intrawound vancomycin, there is a paucity of literature in total hip and knee arthroplasty looking at the effects of intrawound vancomycin on periprosthetic joint infections. Until there are strong, prospective randomized controlled trials in adult reconstruction and other subspecialties of orthopedics, our infectious disease colleagues will continue to caution against widespread vancomycin use in orthopedic surgery for the fear of spreading drug-resistant organisms.
The orthopedic surgery community should not use this paper to spearhead the use of vancomycin powder in every orthopedic wound without prospective, randomized, controlled trial evidence to support its use in each respective subspecialty. Until that data exists, we may safely use this paper to only support our use of intrawound vancomycin powder in high-risk tibial fractures to reduce the risk of gram-positive surgical site infections.
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